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t <br /> State of Cat'rfortaia- tieatth and Welters Agency Department of Health Services <br /> Forte Approved OMB No.20500039(Expires 9.30 Toxic Substances Control Division <br /> Please orint or type, (Form designed€ar use on elitRu 'pach f swifter). Sacramento,California <br /> UNIFORM HAZARDOUS 1 <br /> 1. Generator's US EPA ID No. Manifest 2. Page 1 <br /> !� r ,.,p ument�Jo Information in the shaded areas <br /> WASTE MANIFEST At L (} 4 J Z 4 L °f is not required by Federal law. <br /> 3. Generator's Name an Mailing Address � a 1i t N t A. State Manifest Document Number <br /> 2180 1�wLi tk I-Lc ', e �.�, 8 i 023+ 21 <br /> �f `,5C 51 O N� B. State Generator's,ID <br /> 4. Generator's Phone(�9) 83 — 35 1 5 IIII <br /> 5. T snorter 1 Company Name �{ 6. �U�-S�EPA ID Number C. State Transports s ID 0961 <br /> rOr'�cl \�C � Q��tJSvt C1rl 'YC:r-+ C LJ Z 1 �O D. Transporter'aPhone <br /> n <br /> N 7. Transporter 2 Company Name a. US EPA ID Number E. State Transporter's ID <br /> u7 <br /> to <br /> o F. Transporter's Phone <br /> ao 9. Desi na ed Facility Namean�d;ite Addr � � 10. US EPA ID Number G�Sta F cit' 'd 1 <br /> 3\-Z\ S ►,r-`N o zv:-) 11acility's Phone <br /> I��Y aS�F► Ick C C a <br /> Z 12. Containers t3. Total 14. I. <br /> cc <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> LL No. I Type WI/Vo <br /> 0- (:> td i 1 ` <br /> State 2--2.2-- <br /> G <br /> liii-- <br /> G +� rI� /� EPA/Other <br /> j.. N UU1;♦ YNI �}iA2Aal�C>lsj �I D �y1V,� r ry � � <br /> i' <br /> E b. V State <br /> N <br /> A EPA/Other <br /> 00 <br /> ap T <br /> C R c. State <br /> v <br /> m - EPA/Other <br /> ¢ d. w(. State <br /> W <br /> F- <br /> W <br /> Lu EPA/Other <br /> �Lu J. Additional Descriptions for Materials Listed Above Cf 3'`t K. Handling Ces for Wastes Listed Above <br /> C%ja. yyl b. <br /> Q <br /> Q CL <br /> m w <br /> C. d. <br /> QZ / <br /> Z <br /> 2 15. Special Handling Instructions and Additional Information <br /> OOZ f <br /> i <br /> 16. 6 <br /> c¢.3 GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are Classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> J international and national government regulations. <br /> y If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently availab a to <br /> d <br /> p me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good i <br /> r faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br /> LJ in <br /> Z Printed/Typed Name Signature !J �' Month Day Year <br /> tu <br /> W <br /> I <br /> W R 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LL 5 Pri to �Name <br /> _ , Sig (\ 1 � Month Dai Year <br /> D <br /> O O 1a. Transporter 2 Acknowledgement of Receipt of Materials �a3UL tl ra <br /> Lu R PrinfedrTyped Name Sign urs <br /> T Month Day Year <br /> au <br /> E <br /> R <br /> ?_ 19. Discrepancy Indication Space <br /> C <br /> I <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> TPrintedlTypme Signature -� Mont <br /> Day Year <br /> ed.,pl� <br /> IF <br /> DHS 6022 A(1187) INSTRUCTIONS ON THE BACK <br /> EPA 8700,-22 Yellow: TSDF SENDS THIS COPY TO fRATOR WITHIN 30 DAYS <br /> ev.9-86) Previous editions are obsolete. <br />